A South Australian root cause analysis (RCA) has been performed to address the issue of fall-related hospitalisations in residential aged care services, with the aim to develop strategies to prevent falls and avoid hospitalisation if they occur. Conducted in six South Australian facilities over 12 months, the RCA analysed 47 consecutive fall-related hospitalisations that affected 40 residents. All hospitalisations studied were associated with regular administration of at least one high falls-risk medication. Medication initiations, dose alterations and access to subsidised medical services or radiation were identified as possible root causes of falling and hospitalisation. These findings allowed development of potential strategies for prevention, including pharmacy-generated alerts, reviews and feedback associated with high fall risk medications and access to subsidised mobile imaging services. The original data and conclusions from the RCA can be viewed here.

Contributed by Australian Medication Safety Services Associate – Isabella Singh